Critical Realistic Psychiatry & Other Allied Health Disciplines
The fragmented conceptual models that constitute much of psychopathological theory–and that inform related discourse about psychiatric disorders–, seem to prescribe a bounded solution set to a ‘problem’ that the very discourse itself, produces. In characterizing these problems in such a categorical way–steeped in assumptions about the existence of binaries across and within the “health” versus “disease”–we do little to help ourselves by failing to see the more fundamental biophysical-phenomenological mechanisms of co-emergence that may be in play at every level of analysis. The fundamental nature of our suffering seems anything but clear; however, a tradition of explanatory reductionism (wherever you look in healthcare, be that your mainstream “western medicine”, your “integrative medicine”, your “natural medicine” etc.) appears to have normalized a discourse that creates this illusion of explanatory depth: we mistakenly believe that professionals fully understand a complex mechanism of action by which some structures and processes result in eventual disease . Many people today–practitioners, clients, and the broader public–uncritically accept and conflate these explanatory, pathological ‘maps’ with their ‘territories’. Many seem happy to believe in the idea that somebody–some entity–understands the nature of their problems; and by association, the nature of their “solutions”.
In order to get a sense of whether or not this faith is based in reality, it may be helpful to take a look at some patterns that we are seeing in practice. With respect to matters that are considered to be “of the mind & brain”, we see treatment inefficacy, perpetuation of disease & disorder, certain kinds of injustices and other harms, attrition and barriers to engagement, power imbalances, risk deflection, blame, rising costs, etc. To be clear, we think that this reflects a significant failure. Moreover, we feel that the failure is a responsibility of all of us. We also do not intend to imply that the scientific knowledge and psychophysiological tools that have been developed thus far are useless; these technologies are deeply valued and utilized by some people in some situations. However, there has been appalling stagnation in this space–particularly with respect to disorders marked by chronic cognitive disorganization, perceptual anomalies, altered states of consciousness, the inability to selectively attend to sensory information, psychosis, etc–since the 60s!!! (. In addition to this alarming stagnation, a fundamental part of the problem relates to the socio-structural features of healthcare: the stifling, overwrought, inflexible ecology that we call ‘the mental health system’ renders clients and providers alike unable to easily access those potentially useful technologies that do exist, in an autonomous, self-dignified way. This system design, we argue, just reinforces paternalism, blame, and organizational risk deflection (as opposed to autonomy, symmetrical risk sharing, and inter-relational collaboration, respectively). The failure of the institutional practice of psychiatry and the allied health professions (and really healthcare writ large) warrants immediate attention and action from all stakeholders involved. **We focus here on the failure of the practice as opposed to theoretical or explanatory endeavors because we a) are skeptical of the feasibility of establishing causal models for such dynamic disorders b) find this body of knowledge to only be of value insofar as it has implications for methods/technologies that could be developed in order to ultimately be applied in practice (hopefully effectively).
It is also important to reflect upon the way (the methods or techniques) in which we represent and discuss information in medicine (and all of science). The language and other signaling that we use, implicitly reflects our judgments about, and epistemic orientations toward, the theories to which we subscribe. Much of ‘psychiatry’ as we know it, seems flawed not only in practice, but in many of the conceptual assumptions (and ways of thinking or not thinking about these assumptions) upon which it is inspired.
When we buy into theoretical frameworks with an epistemic attitude of certainty and arrogance, it is likely that we cause more harm than if we were to subscribe to those same theoretical frameworks with an epistemic attitude of ambiguity and openness. In the latter scheme, we essentially mostly think that a conceptual assumption, claim, or principle is a reasonable prior, but we hold this view with a constant awareness of its potential fallibility . We’re not married to our ideas. We’re always open and always ready to prioritize or de-prioritize these ideas in lock-step with incoming information. As “professionals”, when we believe that consumer stakeholders are of “lower epistemic status, perhaps we will “consult” (i.e. feign interest in their opinions, while rarely actually listening). In most cases they alone get the last word. They have most decision making power: from problem formulation, to ‘treatment’ practices, to research scope and design, to policy decisions, etc. This inherently undermines progress. It is these very paternalistic, asymmetrical epistemic attitudes that perpetuate the relational injustices that mediate part of the problem in the first place.
Recently, many psychosocial researcher-practitioners have touted “community-based participatory research” (CBPR) as an innovative and inclusive methodology for addressing stakeholder equity and engagement in this space; however, I question if this way of relating and working together really fundamentally changes epistemic hierarchies and decision making powers . Is it really a new wine or just a new wine bottle?
We suspect that in order to sustainably address the limitations endemic to academic research and professional practice, we need to reflect upon and adapt our ways of relating and practicing such that they function to lessen epistemic injustices and power imbalances within and across all interactions so that we can optimize our collective capacities to integrate information and create better solutions.
Han, Paul K. J., William M. P. Klein, and Neeraj K. Arora. 2011. “Varieties of Uncertainty in Health Care: A Conceptual Taxonomy.” Medical Decision Making 31 (6): 828–38. https://doi.org/10.1177/0272989X10393976. Cite
Borsboom, Denny, Angélique O. J. Cramer, and Annemarie Kalis. 2019. “Brain Disorders? Not Really: Why Network Structures Block Reductionism in Psychopathology Research.” Behavioral and Brain Sciences 42: e2. https://doi.org/10.1017/S0140525X17002266. Cite
We desperately act in ways that are less and less driven by our real values, and that are increasingly driven by our need to be valued. Maybe that anxious, phrenetic energy undermines our ability to stop, reflect, and think. Maybe the best way that we can do to functionally manage is to seek refuge in the comfort of categorical simplicity and binaries: of dramatic hero-villain narratives.
@book{psyd_health_2021,
title = {Health and {Wellness} in {People} {Living} {With} {Serious} {Mental} {Illness}},
isbn = {978-1-61537-379-6},
abstract = {People with serious mental illness get sick and die 10--20 years earlier than their same age cohort. The social determinants are many: stigma associated with mental illness, poverty, ethnicity-based discrimination, higher rates of smoking and alcohol and drug use, and poor diet and exercise patterns, to name a few. Although multiple interventions have emerged as ways to combat these health challenges, additional research is necessary for the continued development and evaluation of strategies. This context serves as the springboard for Health and Wellness in People Living With Serious Mental Illness. Through multiple case vignettes, the book delves into the challenges of health and wellness for people with mental illness -- including those listed above -- summarizing the research on mortality and morbidity in this group as well as information about the status quo on wellness. It also provides a thorough description of community-based participatory research (CBPR), an approach that includes people in a community as partners in all facets of research, rather than just the subjects of that research. CBPR acts as the lens through which this guide considers solutions to these health problems, including integrated services and patient-centered medical homes; medical practices that diminish the iatrogenic effects of psychiatry; psychoeducation; interpersonal supports; and shared decision-making. Co-edited by Patrick Corrigan, with a 30-year history in services research, and Sonya Ballentine, a community-based member of a CBPR team, this volume offers a grounded, real-world illustration of CBPR in practice. Students of psychiatry, practicing clinicians, primary care providers, allied health professionals, policy makers -- all will find, in the pages of this book, a nuanced portrait of the health challenges patients with mental illness face, possible treatment options, and future directions for the field.},
language = {en},
publisher = {American Psychiatric Pub},
author = {Psy.D, Patrick W. Corrigan and Ballentine, Sonya L.},
month = mar,
year = {2021},
note = {ZSCC: NoCitationData[s0]
Google-Books-ID: 7IIiEAAAQBAJ},
keywords = {Medical / Psychiatry / General},
}
People with serious mental illness get sick and die 10–20 years earlier than their same age cohort. The social determinants are many: stigma associated with mental illness, poverty, ethnicity-based discrimination, higher rates of smoking and alcohol and drug use, and poor diet and exercise patterns, to name a few. Although multiple interventions have emerged as ways to combat these health challenges, additional research is necessary for the continued development and evaluation of strategies. This context serves as the springboard for Health and Wellness in People Living With Serious Mental Illness. Through multiple case vignettes, the book delves into the challenges of health and wellness for people with mental illness – including those listed above – summarizing the research on mortality and morbidity in this group as well as information about the status quo on wellness. It also provides a thorough description of community-based participatory research (CBPR), an approach that includes people in a community as partners in all facets of research, rather than just the subjects of that research. CBPR acts as the lens through which this guide considers solutions to these health problems, including integrated services and patient-centered medical homes; medical practices that diminish the iatrogenic effects of psychiatry; psychoeducation; interpersonal supports; and shared decision-making. Co-edited by Patrick Corrigan, with a 30-year history in services research, and Sonya Ballentine, a community-based member of a CBPR team, this volume offers a grounded, real-world illustration of CBPR in practice. Students of psychiatry, practicing clinicians, primary care providers, allied health professionals, policy makers – all will find, in the pages of this book, a nuanced portrait of the health challenges patients with mental illness face, possible treatment options, and future directions for the field.
@article{han_tolerating_2019,
title = {Tolerating uncertainty about conceptual models of uncertainty in health care},
volume = {25},
issn = {1365-2753},
url = {https://onlinelibrary.wiley.com/doi/abs/10.1111/jep.13110},
doi = {10.1111/jep.13110},
language = {en},
number = {2},
urldate = {2020-10-24},
journal = {Journal of Evaluation in Clinical Practice},
author = {Han, Paul K. J. and Djulbegovic, Benjamin},
year = {2019},
note = {ZSCC: 0000004
\_eprint: https://onlinelibrary.wiley.com/doi/pdf/10.1111/jep.13110},
pages = {183--185},
}
@article{van_der_bles_communicating_2019,
title = {Communicating uncertainty about facts, numbers and science},
volume = {6},
issn = {2054-5703, 2054-5703},
url = {https://royalsocietypublishing.org/doi/10.1098/rsos.181870},
doi = {10.1098/rsos.181870},
abstract = {Uncertainty is an inherent part of knowledge, and yet in an era of contested expertise, many shy away from openly communicating their uncertainty about what they know, fearful of their audience's reaction. But what effect does communication of such epistemic uncertainty have? Empirical research is widely scattered across many disciplines. This interdisciplinary review structures and summarizes current practice and research across domains, combining a statistical and psychological perspective. This informs a framework for uncertainty communication in which we identify three objects of uncertainty—facts, numbers and science—and two levels of uncertainty: direct and indirect. An examination of current practices provides a scale of nine expressions of direct uncertainty. We discuss attempts to codify indirect uncertainty in terms of quality of the underlying evidence. We review the limited literature about the effects of communicating epistemic uncertainty on cognition, affect, trust and decision-making. While there is some evidence that communicating epistemic uncertainty does not necessarily affect audiences negatively, impact can vary between individuals and communication formats. Case studies in economic statistics and climate change illustrate our framework in action. We conclude with advice to guide both communicators and future researchers in this important but so far rather neglected field.},
language = {en},
number = {5},
urldate = {2020-10-14},
journal = {Royal Society Open Science},
author = {van der Bles, Anne Marthe and van der Linden, Sander and Freeman, Alexandra L. J. and Mitchell, James and Galvao, Ana B. and Zaval, Lisa and Spiegelhalter, David J.},
month = may,
year = {2019},
pages = {181870},
}
Uncertainty is an inherent part of knowledge, and yet in an era of contested expertise, many shy away from openly communicating their uncertainty about what they know, fearful of their audience's reaction. But what effect does communication of such epistemic uncertainty have? Empirical research is widely scattered across many disciplines. This interdisciplinary review structures and summarizes current practice and research across domains, combining a statistical and psychological perspective. This informs a framework for uncertainty communication in which we identify three objects of uncertainty—facts, numbers and science—and two levels of uncertainty: direct and indirect. An examination of current practices provides a scale of nine expressions of direct uncertainty. We discuss attempts to codify indirect uncertainty in terms of quality of the underlying evidence. We review the limited literature about the effects of communicating epistemic uncertainty on cognition, affect, trust and decision-making. While there is some evidence that communicating epistemic uncertainty does not necessarily affect audiences negatively, impact can vary between individuals and communication formats. Case studies in economic statistics and climate change illustrate our framework in action. We conclude with advice to guide both communicators and future researchers in this important but so far rather neglected field.
@article{borsboom_brain_2018,
title = {Brain disorders? {Not} really… {Why} network structures block reductionism in psychopathology research},
issn = {1469-1825},
shorttitle = {Brain disorders?},
doi = {10.1017/S0140525X17002266},
abstract = {In the past decades, reductionism has dominated both research directions and funding policies in clinical psychology and psychiatry. However, the intense search for the biological basis of mental disorders has not resulted in conclusive reductionist explanations of psychopathology. Recently, network models have been proposed as an alternative framework for the analysis of mental disorders, in which mental disorders arise from the causal interplay between symptoms. In this paper, we show that this conceptualization can help understand why reductionist approaches in psychiatry and clinical psychology are on the wrong track. First, symptom networks preclude the identification of a common cause of symptomatology with a neurobiological condition, because in symptom networks there is no such common cause. Second, symptom network relations depend on the content of mental states and as such feature intentionality. Third, the strength of network relations is highly likely to partially depend on cultural and historical contexts as well as external mechanisms in the environment. Taken together, these properties suggest that, if mental disorders are indeed networks of causally related symptoms, reductionist accounts cannot achieve the level of success associated with reductionist disease models in modern medicine. As an alternative strategy, we propose to interpret network structures in terms of D. C. Dennett's (1987) notion of real patterns, and suggest that, instead of being reducible to a biological basis, mental disorders feature biological and psychological factors that are deeply intertwined in feedback loops. This suggests that neither psychological nor biological levels can claim causal or explanatory priority, and that a holistic research strategy is necessary for progress in the study of mental disorders.},
language = {eng},
journal = {The Behavioral and Brain Sciences},
author = {Borsboom, Denny and Cramer, Angélique and Kalis, Annemarie},
month = jan,
year = {2018},
pmid = {29361992},
note = {ZSCC: NoCitationData[s0] },
pages = {1--54},
}
In the past decades, reductionism has dominated both research directions and funding policies in clinical psychology and psychiatry. However, the intense search for the biological basis of mental disorders has not resulted in conclusive reductionist explanations of psychopathology. Recently, network models have been proposed as an alternative framework for the analysis of mental disorders, in which mental disorders arise from the causal interplay between symptoms. In this paper, we show that this conceptualization can help understand why reductionist approaches in psychiatry and clinical psychology are on the wrong track. First, symptom networks preclude the identification of a common cause of symptomatology with a neurobiological condition, because in symptom networks there is no such common cause. Second, symptom network relations depend on the content of mental states and as such feature intentionality. Third, the strength of network relations is highly likely to partially depend on cultural and historical contexts as well as external mechanisms in the environment. Taken together, these properties suggest that, if mental disorders are indeed networks of causally related symptoms, reductionist accounts cannot achieve the level of success associated with reductionist disease models in modern medicine. As an alternative strategy, we propose to interpret network structures in terms of D. C. Dennett's (1987) notion of real patterns, and suggest that, instead of being reducible to a biological basis, mental disorders feature biological and psychological factors that are deeply intertwined in feedback loops. This suggests that neither psychological nor biological levels can claim causal or explanatory priority, and that a holistic research strategy is necessary for progress in the study of mental disorders.
@article{kauppi_revisiting_2018,
title = {Revisiting antipsychotic drug actions through gene networks associated with schizophrenia},
volume = {175},
issn = {0002-953X},
url = {https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6028303/},
doi = {10.1176/appi.ajp.2017.17040410},
abstract = {Antipsychotic drugs were incidentally discovered in the 1950s, but their mechanisms of action are still not understood. Better understanding of schizophrenia pathogenesis could shed light on actions of current drugs and reveal novel druggable pathways for unmet therapeutic needs. Recent genome-wide association studies offer unprecedented opportunities to characterize disease gene networks and uncover drug-disease relationships. Polygenic overlap between schizophrenia risk genes and antipsychotic drug targets has been demonstrated. However, the specific genes and pathways constituting this overlap are undetermined. Risk genes of polygenic disorders do not operate in isolation, but in combination with other genes. Thus, we utilized protein-protein interaction networks (interactome) to map antipsychotic drug targets (n=88) to networks of schizophrenia risk genes (n=328). Our results showed that schizophrenia risk genes were significantly localized in the interactome (p=0.0015), forming a distinct disease module. Core genes of the module were enriched for genes involved in developmental biology and cognition, which may have a central role in schizophrenia etiology. Intriguingly, antipsychotic drug targets overlapped with the core disease module and comprised multiple pathways beyond dopamine. Some important risk genes like CHRN, PCDH and HCN families were not connected to existing antipsychotics, but may be suitable targets for novel drugs or drug repurposing opportunities to treat other aspects of schizophrenia such as cognitive dysfunction and negative symptoms. This network medicine approach provides a platform to collate information of disease genetics and drug-gene interactions to shift focus from development of antipsychotics to multi-target anti-schizophrenia drugs. This approach is transferable to other diseases.},
number = {7},
urldate = {2021-03-19},
journal = {The American journal of psychiatry},
author = {Kauppi, Karolina and Rosenthal, Sara Brin and Lo, Min-Tzu and Sanyal, Nilotpal and Jiang, Mian and Abagyan, Ruben and McEvoy, Linda K and Andreassen, Ole A and Chen, Chi-Hua},
month = jul,
year = {2018},
pmid = {29495895},
pmcid = {PMC6028303},
note = {ZSCC: 0000010 },
pages = {674--682},
}
Antipsychotic drugs were incidentally discovered in the 1950s, but their mechanisms of action are still not understood. Better understanding of schizophrenia pathogenesis could shed light on actions of current drugs and reveal novel druggable pathways for unmet therapeutic needs. Recent genome-wide association studies offer unprecedented opportunities to characterize disease gene networks and uncover drug-disease relationships. Polygenic overlap between schizophrenia risk genes and antipsychotic drug targets has been demonstrated. However, the specific genes and pathways constituting this overlap are undetermined. Risk genes of polygenic disorders do not operate in isolation, but in combination with other genes. Thus, we utilized protein-protein interaction networks (interactome) to map antipsychotic drug targets (n=88) to networks of schizophrenia risk genes (n=328). Our results showed that schizophrenia risk genes were significantly localized in the interactome (p=0.0015), forming a distinct disease module. Core genes of the module were enriched for genes involved in developmental biology and cognition, which may have a central role in schizophrenia etiology. Intriguingly, antipsychotic drug targets overlapped with the core disease module and comprised multiple pathways beyond dopamine. Some important risk genes like CHRN, PCDH and HCN families were not connected to existing antipsychotics, but may be suitable targets for novel drugs or drug repurposing opportunities to treat other aspects of schizophrenia such as cognitive dysfunction and negative symptoms. This network medicine approach provides a platform to collate information of disease genetics and drug-gene interactions to shift focus from development of antipsychotics to multi-target anti-schizophrenia drugs. This approach is transferable to other diseases.
@article{borsboom_network_2017,
title = {A network theory of mental disorders},
volume = {16},
issn = {2051-5545},
url = {https://onlinelibrary.wiley.com/doi/abs/10.1002/wps.20375},
doi = {10.1002/wps.20375},
abstract = {In recent years, the network approach to psychopathology has been advanced as an alternative way of conceptualizing mental disorders. In this approach, mental disorders arise from direct interactions between symptoms. Although the network approach has led to many novel methodologies and substantive applications, it has not yet been fully articulated as a scientific theory of mental disorders. The present paper aims to develop such a theory, by postulating a limited set of theoretical principles regarding the structure and dynamics of symptom networks. At the heart of the theory lies the notion that symptoms of psychopathology are causally connected through myriads of biological, psychological and societal mechanisms. If these causal relations are sufficiently strong, symptoms can generate a level of feedback that renders them self-sustaining. In this case, the network can get stuck in a disorder state. The network theory holds that this is a general feature of mental disorders, which can therefore be understood as alternative stable states of strongly connected symptom networks. This idea naturally leads to a comprehensive model of psychopathology, encompassing a common explanatory model for mental disorders, as well as novel definitions of associated concepts such as mental health, resilience, vulnerability and liability. In addition, the network theory has direct implications for how to understand diagnosis and treatment, and suggests a clear agenda for future research in psychiatry and associated disciplines.},
language = {en},
number = {1},
urldate = {2020-10-13},
journal = {World Psychiatry},
author = {Borsboom, Denny},
year = {2017},
note = {ZSCC: 0000706
\_eprint: https://onlinelibrary.wiley.com/doi/pdf/10.1002/wps.20375},
keywords = {Psychopathology, diagnosis, mental disorders, mental health, network approach, resilience, symptom networks, treatment, vulnerability},
pages = {5--13},
}
In recent years, the network approach to psychopathology has been advanced as an alternative way of conceptualizing mental disorders. In this approach, mental disorders arise from direct interactions between symptoms. Although the network approach has led to many novel methodologies and substantive applications, it has not yet been fully articulated as a scientific theory of mental disorders. The present paper aims to develop such a theory, by postulating a limited set of theoretical principles regarding the structure and dynamics of symptom networks. At the heart of the theory lies the notion that symptoms of psychopathology are causally connected through myriads of biological, psychological and societal mechanisms. If these causal relations are sufficiently strong, symptoms can generate a level of feedback that renders them self-sustaining. In this case, the network can get stuck in a disorder state. The network theory holds that this is a general feature of mental disorders, which can therefore be understood as alternative stable states of strongly connected symptom networks. This idea naturally leads to a comprehensive model of psychopathology, encompassing a common explanatory model for mental disorders, as well as novel definitions of associated concepts such as mental health, resilience, vulnerability and liability. In addition, the network theory has direct implications for how to understand diagnosis and treatment, and suggests a clear agenda for future research in psychiatry and associated disciplines.
@article{hyman_revitalizing_2014,
title = {Revitalizing {Psychiatric} {Therapeutics}},
volume = {39},
copyright = {2014 American College of Neuropsychopharmacology},
issn = {1740-634X},
url = {https://www.nature.com/articles/npp2013181},
doi = {10.1038/npp.2013.181},
abstract = {Despite high prevalence and enormous unmet medical need, the pharmaceutical industry has recently de-emphasized neuropsychiatric disorders as ‘too difficult’ a challenge to warrant major investment. Here I describe major obstacles to drug discovery and development including a lack of new molecular targets, shortcomings of current animal models, and the lack of biomarkers for clinical trials. My major focus, however, is on new technologies and scientific approaches to neuropsychiatric disorders that give promise for revitalizing therapeutics and may thus answer industry’s concerns.},
language = {en},
number = {1},
urldate = {2020-06-29},
journal = {Neuropsychopharmacology},
author = {Hyman, Steven E.},
month = jan,
year = {2014},
note = {Number: 1
Publisher: Nature Publishing Group},
pages = {220--229},
}
Despite high prevalence and enormous unmet medical need, the pharmaceutical industry has recently de-emphasized neuropsychiatric disorders as ‘too difficult’ a challenge to warrant major investment. Here I describe major obstacles to drug discovery and development including a lack of new molecular targets, shortcomings of current animal models, and the lack of biomarkers for clinical trials. My major focus, however, is on new technologies and scientific approaches to neuropsychiatric disorders that give promise for revitalizing therapeutics and may thus answer industry’s concerns.
@article{whooley_nosological_2014,
title = {Nosological {Reflections}: {The} {Failure} of \textit{{DSM}} -5, the {Emergence} of {RDoC}, and the {Decontextualization} of {Mental} {Distress}},
volume = {4},
issn = {2156-8693, 2156-8731},
shorttitle = {Nosological {Reflections}},
url = {http://journals.sagepub.com/doi/10.1177/2156869313519114},
doi = {10.1177/2156869313519114},
abstract = {Since the establishment of the symptoms-based categories in the Diagnostic and Statistical Manual of Mental Disorders (DSM), Third Edition, sociologists have raised concerns about the DSM’s failure to appreciate social, contextual factors when defining mental disorders. The author describes recent developments in psychiatric nosology—the DSM-5 revision process and the emergence of the Research Domain Criteria (RDoC)—and then considers their implications for decontextualization. Drawing on in-depth interviews with psychiatrists involved in the DSM-5 controversy and a content analysis of key documents, the author first recounts the ambitious DSM-5 revisions, illuminating the DSM-5 Task Force’s embrace of dimensionalization as a solution to the problem of validity and the ultimate rejection of this ‘‘paradigm shift’’ by psychiatrists. The Task Force’s failures prompted the National Institute of Mental Health to promote RDoC as an alternative nosological framework that eschews DSM categories altogether. Next, the author explores the ramifications of these events for decontextualization, which neither DSM-5 nor RDoC explicitly addresses, demonstrating how RDoC is poised to escalate decontextualization through its brain-centric conceptualization of mental disorders. To counteract these developments, sociologists should continue to promote ways of defining mental distress that underscore its social embeddedness.},
language = {en},
number = {2},
urldate = {2020-03-18},
journal = {Society and Mental Health},
author = {Whooley, Owen},
month = jul,
year = {2014},
pages = {92--110},
}
Since the establishment of the symptoms-based categories in the Diagnostic and Statistical Manual of Mental Disorders (DSM), Third Edition, sociologists have raised concerns about the DSM’s failure to appreciate social, contextual factors when defining mental disorders. The author describes recent developments in psychiatric nosology—the DSM-5 revision process and the emergence of the Research Domain Criteria (RDoC)—and then considers their implications for decontextualization. Drawing on in-depth interviews with psychiatrists involved in the DSM-5 controversy and a content analysis of key documents, the author first recounts the ambitious DSM-5 revisions, illuminating the DSM-5 Task Force’s embrace of dimensionalization as a solution to the problem of validity and the ultimate rejection of this ‘‘paradigm shift’’ by psychiatrists. The Task Force’s failures prompted the National Institute of Mental Health to promote RDoC as an alternative nosological framework that eschews DSM categories altogether. Next, the author explores the ramifications of these events for decontextualization, which neither DSM-5 nor RDoC explicitly addresses, demonstrating how RDoC is poised to escalate decontextualization through its brain-centric conceptualization of mental disorders. To counteract these developments, sociologists should continue to promote ways of defining mental distress that underscore its social embeddedness.
@article{han_conceptual_2013,
title = {Conceptual, {Methodological}, and {Ethical} {Problems} in {Communicating} {Uncertainty} in {Clinical} {Evidence}},
volume = {70},
issn = {1077-5587},
url = {https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4238424/},
doi = {10.1177/1077558712459361},
abstract = {The communication of uncertainty in clinical evidence is an important endeavor that poses difficult conceptual, methodological, and ethical problems. Conceptual problems include logical paradoxes in the meaning of probability and “ambiguity”— second-order uncertainty arising from the lack of reliability, credibility, or adequacy of probability information. Methodological problems include questions about optimal methods for representing fundamental uncertainties and for communicating these uncertainties in clinical practice. Ethical problems include questions about whether communicating uncertainty enhances or diminishes patient autonomy and produces net benefits or harms. This article reviews the limited but growing literature on these problems and efforts to address them and identifies key areas of focus for future research. It is argued that the critical need moving forward is for greater conceptual clarity and consistent representational methods that make the meaning of various uncertainties understandable, and for clinical interventions to support patients in coping with uncertainty in decision making.},
number = {1 0},
urldate = {2020-10-24},
journal = {Medical care research and review : MCRR},
author = {Han, Paul K. J.},
month = feb,
year = {2013},
pmid = {23132891},
pmcid = {PMC4238424},
note = {ZSCC: 0000117 },
pages = {14S--36S},
}
The communication of uncertainty in clinical evidence is an important endeavor that poses difficult conceptual, methodological, and ethical problems. Conceptual problems include logical paradoxes in the meaning of probability and “ambiguity”— second-order uncertainty arising from the lack of reliability, credibility, or adequacy of probability information. Methodological problems include questions about optimal methods for representing fundamental uncertainties and for communicating these uncertainties in clinical practice. Ethical problems include questions about whether communicating uncertainty enhances or diminishes patient autonomy and produces net benefits or harms. This article reviews the limited but growing literature on these problems and efforts to address them and identifies key areas of focus for future research. It is argued that the critical need moving forward is for greater conceptual clarity and consistent representational methods that make the meaning of various uncertainties understandable, and for clinical interventions to support patients in coping with uncertainty in decision making.
@article{kvaale_side_2013,
title = {The ‘side effects’ of medicalization: {A} meta-analytic review of how biogenetic explanations affect stigma},
volume = {33},
issn = {02727358},
shorttitle = {The ‘side effects’ of medicalization},
url = {https://linkinghub.elsevier.com/retrieve/pii/S0272735813000883},
doi = {10.1016/j.cpr.2013.06.002},
abstract = {Reducing stigma is crucial for facilitating recovery from psychological problems. Viewing these problems biomedically may reduce the tendency to blame affected persons, but critics have cautioned that it could also increase other facets of stigma. We report on the first meta-analytic review of the effects of biogenetic explanations on stigma. A comprehensive search yielded 28 eligible experimental studies. Four separate meta-analyses (Ns = 1207–3469) assessed the effects of biogenetic explanations on blame, perceived dangerousness, social distance, and prognostic pessimism. We found that biogenetic explanations reduce blame (Hedges g = − 0.324) but induce pessimism (Hedges g = 0.263). We also found that biogenetic explanations increase endorsement of the stereotype that people with psychological problems are dangerous (Hedges g = 0.198), although this result could reflect publication bias. Finally, we found that biogenetic explanations do not typically affect social distance. Promoting biogenetic explanations to alleviate blame may induce pessimism and set the stage for self-fulfilling prophecies that could hamper recovery from psychological problems.},
language = {en},
number = {6},
urldate = {2020-04-02},
journal = {Clinical Psychology Review},
author = {Kvaale, Erlend P. and Haslam, Nick and Gottdiener, William H.},
month = aug,
year = {2013},
note = {ZSCC: 0000286},
pages = {782--794},
}
Reducing stigma is crucial for facilitating recovery from psychological problems. Viewing these problems biomedically may reduce the tendency to blame affected persons, but critics have cautioned that it could also increase other facets of stigma. We report on the first meta-analytic review of the effects of biogenetic explanations on stigma. A comprehensive search yielded 28 eligible experimental studies. Four separate meta-analyses (Ns = 1207–3469) assessed the effects of biogenetic explanations on blame, perceived dangerousness, social distance, and prognostic pessimism. We found that biogenetic explanations reduce blame (Hedges g = − 0.324) but induce pessimism (Hedges g = 0.263). We also found that biogenetic explanations increase endorsement of the stereotype that people with psychological problems are dangerous (Hedges g = 0.198), although this result could reflect publication bias. Finally, we found that biogenetic explanations do not typically affect social distance. Promoting biogenetic explanations to alleviate blame may induce pessimism and set the stage for self-fulfilling prophecies that could hamper recovery from psychological problems.
@article{schwab_epistemic_2012,
title = {Epistemic {Humility} and {Medical} {Practice}: {Translating} {Epistemic} {Categories} into {Ethical} {Obligations}},
volume = {37},
issn = {0360-5310, 1744-5019},
shorttitle = {Epistemic {Humility} and {Medical} {Practice}},
url = {https://academic.oup.com/jmp/article-lookup/doi/10.1093/jmp/jhr054},
doi = {10.1093/jmp/jhr054},
abstract = {Physicians and other medical practitioners make untold numbers of judgments about patient care on a daily, weekly, and monthly basis. These judgments fall along a number of spectrums, from the mundane to the tragic, from the obvious to the challenging. Under the rubric of evidence-based medicine, these judgments will be informed by the robust conclusions of medical research. In the ideal circumstance medical research makes the best decision obvious to the trained professional. Even when practice approximates this ideal, it does so unevenly. Judgments in medical practice are always accompanied by uncertainty, and this uncertainty is a fickle companion—constant in its presence but inconstant in its expression. This feature of medical judgments gives rise to the moral responsibility of medical practitioners to be epistemically humble. This requires the recognition and communication of the uncertainty that accompanies their judgment as well as a commitment to avoiding intuitive innovations.},
language = {en},
number = {1},
urldate = {2020-07-01},
journal = {Journal of Medicine and Philosophy},
author = {Schwab, A.},
month = feb,
year = {2012},
note = {ZSCC: 0000031},
pages = {28--48},
}
Physicians and other medical practitioners make untold numbers of judgments about patient care on a daily, weekly, and monthly basis. These judgments fall along a number of spectrums, from the mundane to the tragic, from the obvious to the challenging. Under the rubric of evidence-based medicine, these judgments will be informed by the robust conclusions of medical research. In the ideal circumstance medical research makes the best decision obvious to the trained professional. Even when practice approximates this ideal, it does so unevenly. Judgments in medical practice are always accompanied by uncertainty, and this uncertainty is a fickle companion—constant in its presence but inconstant in its expression. This feature of medical judgments gives rise to the moral responsibility of medical practitioners to be epistemically humble. This requires the recognition and communication of the uncertainty that accompanies their judgment as well as a commitment to avoiding intuitive innovations.
@article{thomas_anomalies_2012,
title = {The anomalies of evidence‐based medicine in psychiatry: time to rethink the basis of mental health practice},
volume = {17},
issn = {1361-9322},
shorttitle = {The anomalies of evidence‐based medicine in psychiatry},
url = {https://www.emerald.com/insight/content/doi/10.1108/13619321211287265/full/html},
doi = {10.1108/13619321211287265},
abstract = {Purpose – Evidence-based medicine (EBM) is a technical and scientific paradigm in clinical practice that has delivered major improvements in the outcome of care in medicine and surgery. However, its value in psychiatry is much less clear. The purpose of the paper is thus to examine its value by subjecting empirical evidence from EBM to a conceptual analysis using the philosophy of Thomas Kuhn. Design/methodology/approach – The authors examine evidence drawn from meta-analyses of RCTs investigating the efficacy of specific treatments for depression in the form of antidepressant drugs and CBT. This shows that the non-specific aspects of treatment, the placebo effect and the quality of the therapeutic alliance as seen by the patient, are more important in determining outcome than the specific elements (active drug, specific therapeutic elements of CBT).},
language = {en},
number = {3},
urldate = {2020-03-18},
journal = {Mental Health Review Journal},
author = {Thomas, Philip and Bracken, Pat and Timimi, Sami},
month = sep,
year = {2012},
keywords = {clinical medicine, depression, evidence-based medicine, mental illness, recovery},
pages = {152--162},
}
Purpose – Evidence-based medicine (EBM) is a technical and scientific paradigm in clinical practice that has delivered major improvements in the outcome of care in medicine and surgery. However, its value in psychiatry is much less clear. The purpose of the paper is thus to examine its value by subjecting empirical evidence from EBM to a conceptual analysis using the philosophy of Thomas Kuhn. Design/methodology/approach – The authors examine evidence drawn from meta-analyses of RCTs investigating the efficacy of specific treatments for depression in the form of antidepressant drugs and CBT. This shows that the non-specific aspects of treatment, the placebo effect and the quality of the therapeutic alliance as seen by the patient, are more important in determining outcome than the specific elements (active drug, specific therapeutic elements of CBT).
@article{de_vreese_explanatory_2010,
title = {Explanatory pluralism in the medical sciences: {Theory} and practice},
volume = {31},
issn = {1386-7415, 1573-1200},
shorttitle = {Explanatory pluralism in the medical sciences},
url = {http://link.springer.com/10.1007/s11017-010-9156-7},
doi = {10.1007/s11017-010-9156-7},
abstract = {Explanatory pluralism is the view that the best form and level of explanation depends on the kind of question one seeks to answer by the explanation, and that in order to answer all questions in the best way possible, we need more than one form and level of explanation. In the first part of this article, we argue that explanatory pluralism holds for the medical sciences, at least in theory. However, in the second part of the article we show that medical research and practice is actually not fully and truly explanatory pluralist yet. Although the literature demonstrates a slowly growing interest in non-reductive explanations in medicine, the dominant approach in medicine is still methodologically reductionist. This implies that non-reductive explanations often do not get the attention they deserve. We argue that the field of medicine could benefit greatly by reconsidering its reductive tendencies and becoming fully and truly explanatory pluralist. Nonetheless, trying to achieve the right balance in the search for and application of reductive and non-reductive explanations will in any case be a difficult exercise.},
language = {en},
number = {5},
urldate = {2020-03-18},
journal = {Theoretical Medicine and Bioethics},
author = {De Vreese, Leen and Weber, Erik and Van Bouwel, Jeroen},
month = oct,
year = {2010},
pages = {371--390},
}
Explanatory pluralism is the view that the best form and level of explanation depends on the kind of question one seeks to answer by the explanation, and that in order to answer all questions in the best way possible, we need more than one form and level of explanation. In the first part of this article, we argue that explanatory pluralism holds for the medical sciences, at least in theory. However, in the second part of the article we show that medical research and practice is actually not fully and truly explanatory pluralist yet. Although the literature demonstrates a slowly growing interest in non-reductive explanations in medicine, the dominant approach in medicine is still methodologically reductionist. This implies that non-reductive explanations often do not get the attention they deserve. We argue that the field of medicine could benefit greatly by reconsidering its reductive tendencies and becoming fully and truly explanatory pluralist. Nonetheless, trying to achieve the right balance in the search for and application of reductive and non-reductive explanations will in any case be a difficult exercise.
@article{weisberg_seductive_2008,
title = {The {Seductive} {Allure} of {Neuroscience} {Explanations}},
volume = {20},
issn = {0898-929X},
url = {https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2778755/},
doi = {10.1162/jocn.2008.20040},
abstract = {Explanations of psychological phenomena seem to generate more public interest when they contain neuroscientific information. Even irrelevant neuroscience information in an explanation of a psychological phenomenon may interfere with people’s abilities to critically consider the underlying logic of this explanation. We tested this hypothesis by giving naïve adults, students in a neuroscience course, and neuroscience experts brief descriptions of psychological phenomena followed by one of four types of explanation, according to a 2 (good explanation vs. bad explanation) × 2 (without neuroscience vs. with neuroscience) design. Crucially, the neuroscience information was irrelevant to the logic of the explanation, as confirmed by the expert subjects. Subjects in all three groups judged good explanations as more satisfying than bad ones. But subjects in the two nonexpert groups additionally judged that explanations with logically irrelevant neuroscience information were more satisfying than explanations without. The neuroscience information had a particularly striking effect on nonexperts’ judgments of bad explanations, masking otherwise salient problems in these explanations.},
number = {3},
urldate = {2020-07-06},
journal = {Journal of cognitive neuroscience},
author = {Weisberg, Deena Skolnick and Keil, Frank C. and Goodstein, Joshua and Rawson, Elizabeth and Gray, Jeremy R.},
month = mar,
year = {2008},
pmid = {18004955},
pmcid = {PMC2778755},
note = {ZSCC: 0001112 },
pages = {470--477},
}
Explanations of psychological phenomena seem to generate more public interest when they contain neuroscientific information. Even irrelevant neuroscience information in an explanation of a psychological phenomenon may interfere with people’s abilities to critically consider the underlying logic of this explanation. We tested this hypothesis by giving naïve adults, students in a neuroscience course, and neuroscience experts brief descriptions of psychological phenomena followed by one of four types of explanation, according to a 2 (good explanation vs. bad explanation) × 2 (without neuroscience vs. with neuroscience) design. Crucially, the neuroscience information was irrelevant to the logic of the explanation, as confirmed by the expert subjects. Subjects in all three groups judged good explanations as more satisfying than bad ones. But subjects in the two nonexpert groups additionally judged that explanations with logically irrelevant neuroscience information were more satisfying than explanations without. The neuroscience information had a particularly striking effect on nonexperts’ judgments of bad explanations, masking otherwise salient problems in these explanations.
@book{noauthor_philosophical_nodate,
title = {Philosophical {Issues} in {Psychiatry} {III}: {The} {Nature} and {Sources} of {Historical} {Change}},
isbn = {978-0-19-179297-7},
shorttitle = {Philosophical {Issues} in {Psychiatry} {III}},
url = {https://oxfordmedicine.com/view/10.1093/med/9780198725978.001.0001/med-9780198725978},
abstract = {"Philosophical Issues in Psychiatry III" published on by Oxford University Press.},
language = {en\_US},
urldate = {2021-06-21},
publisher = {Oxford University Press},
note = {Publication Title: Philosophical Issues in Psychiatry III},
}
"Philosophical Issues in Psychiatry III" published on by Oxford University Press.
@book{alatas_can_nodate,
title = {Can {Stem} {Cell} {Transplant} {Be} a {New} {Alternative} in the {Treatment} of {Schizophrenia}?},
abstract = {Until recently, it was thought that there is no neuronal regeneration and neuron loss is irreversible, but today the exist-ence of neural regeneration and neural plasticity have been documented. The effectiveness of stem cell treatment in nu-merous degenerative diseases, as well as some neurodegenerative diseases, has created hopes toward the use of stem cell treatment in schizophrenia, which is a disease that progresses with neuronal degeneration and loss of neurons, and is characterized with worsening clinical outcomes and impairment.},
author = {Alataş, Esra and Günay, Gamer},
note = {ZSCC: 0000000},
}
Until recently, it was thought that there is no neuronal regeneration and neuron loss is irreversible, but today the exist-ence of neural regeneration and neural plasticity have been documented. The effectiveness of stem cell treatment in nu-merous degenerative diseases, as well as some neurodegenerative diseases, has created hopes toward the use of stem cell treatment in schizophrenia, which is a disease that progresses with neuronal degeneration and loss of neurons, and is characterized with worsening clinical outcomes and impairment.
@article{bracken_szasz_nodate,
title = {From {Szasz} to {Foucault}: {On} the {Role} of {Critical} {Psychiatry}},
abstract = {In this article, we examine the different ways in which Thomas Szasz and Michel Foucault have challenged dominant perspectives within psychiatry. We identify, analyze, and compare the central elements of their respective discourses on psychiatry and show that although they are often bracketed together, in fact there are certain fundamental differences between Szasz and Foucault. Of most importance is their contrasting ways of characterizing the nature and role of critical thought. Whereas Szasz’s analysis is predicated on a number of binary distinctions, Foucault works to overcome such distinctions. In the past ten years, a new movement of critical psychiatry has emerged. Although this shares certain concerns with the critical psychiatry of the 1960s and 1970s, there are substantial differences. We argue that this discourse is more resonant with the Foucauldian approach.},
language = {en},
author = {Bracken, Pat and Thomas, Philip},
note = {ZSCC: 0000082},
pages = {11},
}
In this article, we examine the different ways in which Thomas Szasz and Michel Foucault have challenged dominant perspectives within psychiatry. We identify, analyze, and compare the central elements of their respective discourses on psychiatry and show that although they are often bracketed together, in fact there are certain fundamental differences between Szasz and Foucault. Of most importance is their contrasting ways of characterizing the nature and role of critical thought. Whereas Szasz’s analysis is predicated on a number of binary distinctions, Foucault works to overcome such distinctions. In the past ten years, a new movement of critical psychiatry has emerged. Although this shares certain concerns with the critical psychiatry of the 1960s and 1970s, there are substantial differences. We argue that this discourse is more resonant with the Foucauldian approach.
@article{boisvert_iatrogenic_nodate,
title = {Iatrogenic {Symptoms} in {Psychotherapy} {A} {Theoretical} {Exploration} of the {Potential} {Impact} of {Labels}, {Language}, and {Belief} {Systems}},
language = {en},
journal = {AMERICAN JOURNAL OF PSYCHOTHERAPY},
author = {Boisvert, Charles M},
note = {ZSCC: 0000072},
pages = {16},
}
![There are no patients without comorbidity [link]](http://bibbase.org/img/filetypes/link.svg "Paper")
